Sixty-four patients with symptomatic erosive hand osteoarthritis were randomized to receive methotrexate (MTX) 10 mg weekly (n=32) or placebo (n=32). The primary outcome was the change in pain, measured via a visual analogue scale (VAS), from baseline to 3 months. Secondary outcomes included pain at 12 months, function, and structural progression assessed using the Verbruggen-Veys (VV) and Ghent University Scoring System (GUSS) radiographic scores, as well as MRI assessments. Outcomes were evaluated over 12 months. Overall, the study revealed no significant differences between MTX and placebo regarding pain reduction or functional improvement. However, structural progression was slower in the MTX group, with more erosive joints transitioning to remodeling (27% vs 15%, p=0.03). The findings suggest MTX may have some structural benefits but does not significantly improve pain or function.